About
Severe adverse reaction to some medications causing major skin and mucous membrane abnormalities potentially life-threatening.
Assess
Aches, pains, conjunctivitis, fatigue, skin sensitivity, erythema, fever, cough, sore throat, headache, blisters covering skin and mucous membranes inside mouth, genitalia, eyes, skin weeping, peeling of skin, shedding of toenails, fingernails
Complications
Sepsis, keratoconjunctivitis, dehydration, electrolyte imbalance, death
Diagnosis
- Impaired tissue integrity related to epidermal loss.
- Fluid volume deficit related to insensible fluid losses via open skin areas.
- Acute pain related to actual tissue damage.
- Body image disturbance related to altered appearance of skin and mucous membranes.
- Risk for infection related to break in skin integrity.
Goals
- The client will state a pain level less than 4 after medication intervention.
- The client will maintain stable body temperature.
- The client will remain free from infection.
- The client will have a decrease in erythema and blisters.
- The client will maintain adequate hydration and electrolytes within normal ranges.
- The client will remain free from complications.
- The client will be able to discuss feelings regarding diagnosis and treatment.
Interventions
- Assess vitals, pulse oximetry, electrolytes, WBC's, pain levels, sin areas involved.
- Monitor changes in labs, vitals, and pain levels.
- Turn patient carefully and gently to monitor all skin areas and prevent skin breakdown.
- Apply warm moist compresses and topical agents as indicated by physician.
- encourage active range of motion to prevent immobility complications.
- Provide frequent oral care with oral anesthetics several times a day.
- Monitor intake and output and encourage fluid and food intake.
- If oral intake is poor, plan for tube feedings to increase caloric intake.
- use heat lamps, heat shield and cotton blankets to maintain body temperature.
- Administer pain medications and evaluate response.
- Provide opportunities for client to verbalize concerns, feelings, and fears related to diagnosis and treatment.
- Maintain strict asepsis and monitor for signs and symptoms of infection requiring immediate intervention to prevent sepsis.
- Administer eye drops or lubricants frequently to prevent corneal scarring, tearing and dryness.
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